So you’ve been diligent…
You’ve done the calf raises. You’ve stretched your calves. You’ve rolled them. Iced them. Maybe even Googled “Achilles tendinopathy rehab” at 2 am when your heel flared up again after training.
However, weeks – or months – later, it’s still sore.
Here’s the truth:
Not all pain at the back of your heel is your Achilles tendon.
And if you’ve been treating the wrong thing, no wonder you’re frustrated.
Let’s unpack why that stubborn pain isn’t shifting… and what you can do about it.
Posterior Heel Pain: More Than Just the Achilles
Most athletes (and many clinicians) default to “Achilles tendinopathy” when pain shows up around the back of the ankle. But “Achilles” is a complex zone. Here are some common (and commonly missed) conditions we see in the clinic:
🔍 1. Insertional Achilles Tendinopathy
Where: Where the Achilles attaches to the heel bone
Feels like: Pain right at the bony insertion – especially when compressing it (e.g., uphill running, stretching, shoes rubbing)
Telltale signs:
- Aggravated by dorsiflexion (toes up), not helped by stretching
- Pain on pinching the tendon against the bone
- Often stiffer in the morning or after sitting
🛠️ Rehab Tip:
Heavy isometric holds and heel drops from the floor (not off a step) are more appropriate. Excessive stretching usually flares this up.
🔍 2. Achilles Paratenon Irritation (Paratenonitis)
Where: The thin sheath that surrounds the Achilles tendon
Feels like: Burning, swelling or friction-like sensations along the tendon, often with visible creaking (crepitus)
Telltale signs:
- Pain increases with repeated movement
- Tender along the tendon but not deep or at insertion
- Often more acute or inflamed than classic mid-portion Achilles pain
🛠️ Rehab Tip:
Focus on reducing load and irritation first – short-term rest, ice, and offloading—before gradually returning to movement. Calf loading needs to be gentle and non-aggravating.
🔍 3. Retrocalcaneal Bursitis
Where: A fluid-filled sac between the Achilles and heel bone
Feels like: Deep ache or pressure pain just in front of the Achilles, especially in tight shoes or with compression
Telltale signs:
- Squeeze test: pain when pinching above the heel on either side
- Swelling on either side of the tendon
- Worse in stiff shoes or after dorsiflexion-heavy activities
🛠️ Rehab Tip:
Reduce compression and inflammation: avoid tight shoes, elevate heel temporarily, and gradually reload as inflammation settles.
🔍 4. Posterior Ankle Impingement
Where: Compression of soft tissue between heel and shin bones, often in plantarflexion
Feels like: Sharp, pinching pain deep in the back of the ankle during explosive toe-pointing (e.g., ballet, sprinting, kicking)
Telltale signs:
- Pain during jumping or pushing off
- No tendon thickening
- Positive with forced plantarflexion in testing
🛠️ Rehab Tip:
Strengthen posterior chain without provoking pain. Mobilise the ankle joint and potentially modify technique (e.g., landing mechanics).
✅ How We Tailor Your Rehab
At Gold Coast Physio & Sports Health, we don’t just throw calf raises at every sore heel. Here’s what we do instead:
- Detailed Assessment: Palpation, movement tests, imaging if needed
- Precise Diagnosis: Is it compressive? Tractional? Inflammatory?
- Goal-Oriented Plan: You’re not here to treat anatomy – you’re here to run, train, and compete again
- Progressive Rehab: The right load at the right time, for the right structure
💬 The Bottom Line
If you’ve been diligently working on your “Achilles” but still can’t run, jump, or lift pain-free, it might be time to look deeper.
Posterior heel pain is not one-size-fits-all, and a plan that’s just “do calf raises” or “stretch more” could be keeping you stuck.
🏃♂️ Ready to Move Forward?
Book in with one of our sports physios for a targeted assessment.
Let’s get you back to doing what you love – without that constant heel ache holding you back.
Written by Physiotherapist, Sam McLaren
